Community Health Workers: Key Agents for Reducing Child Mortality

Henry Perry, M.D., Ph.D., MPH, is a senior associate in the Department of International Health at Johns Hopkins University’s Bloomberg School of Public Health in Baltimore, Md.

During the past half-century, there has been a growing recognition that community-based workers can make an important contribution to the health of communities, especially in resource-constrained settings. These workers are known by many names, but most commonly Community Health Workers (CHWs). With initial training of usually 6 weeks or less, they can effectively provide different types of services from community mobilization to health education to preventive screening to family planning education to identifying persons with symptoms of leprosy or tuberculosis to diagnosis and treatment of life-threatening childhood illness, and many more. These persons may work as volunteers or for modest incentives or salaries.

Based on early projects that utilized CHWs effectively in a number of developing countries, the seminal International Conference on Primary Health Care — sponsored by the World Health Organization and UNICEF in 1978 and attended by high-level representatives of almost every country in the world — recognized that in many settings where facilities and highly trained health workers are scarce, CHWs can become an important part of a primary health care system.

The Declaration of Alma Ata, adopted at the conference, called for basic health services — promotive, preventive, curative and rehabilitative — to be provided by “health workers, including physicians, nurses, midwives, auxiliaries and community workers [italics added] as applicable, as well as traditional practitioners as needed, suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community.” The Declaration also recognized the importance of providing health services “as close as possible to where people live and work.”

A ChildFund community health worker in Honduras.

Progress in incorporating CHWs into the formal health systems of resource-constrained settings has been only gradual, often moving in fits and starts and sometimes in reverse (in response to disappointing results from poorly designed and inadequately implemented large-scale CHW programs in the 1980s). However, evidence and experience during the past decade have led to a renewed interest in CHWs as a key agent for reducing child mortality as well as addressing other health priorities.

A rapidly growing number of studies demonstrate that CHWs make it possible to expand access and improve coverage of essential services, particularly in remote and poorly served populations, thereby improving equity. CHWs have been shown to play critical roles in interventions to

reduce child mortality, including distribution of vitamin A capsules and other critical micronutrients

promote water and sanitation education (hand washing, point-of-use water treatment and safe water storage, latrine construction and promotion of latrine use)

distribute mosquito nets and assist communities in draining stagnant water to eliminate breeding grounds for mosquitoes

promote healthy behaviors such as appropriate breastfeeding (exclusive breastfeeding during the first six months of life and continued breastfeeding until at least one year of age)

provide hygiene and cleanliness education

ensure appropriate care of newborns

promote and facilitate immunizations for mothers and children.

Many countries can benefit by scaling up integrated community case management of pneumonia, diarrhea, malaria and newborn sepsis and promotion of healthy behaviors that can save the lives of millions of children who are dying from preventable causes.

CHWs are one of the essential ingredients for making this possible — along with political commitment, professional leadership, long-term sustainable training, support and supervision from the health system and reliable logistical support of basic medicines and supplies. A strong commitment by the world community to these activities, which are some of the most cost-effective approaches to promoting global equity in health, is a moral imperative for today and tomorrow.

James Grant, the renowned executive director of UNICEF from 1980 to 1995 and champion of what is often referred to as the First Child Survival Revolution, repeatedly reminded us that “morality must march with capacity.”

We now know that CHWs can have the capacity to make a difference between life and death for millions of children. The moral imperative for the world community is to ensure that health systems and underserved communities support CHWs in attaining this capacity.

Community health workers are vital to the success of numerous ChildFund projects in countries such as Senegal, Kenya and Honduras.